Pediatric Advanced Life Support (PALS): Clinical Overview

Pediatric Advanced Life Support (PALS) is an organized approach to recognizing and treating life-threatening respiratory and cardiovascular emergencies in infants and children.

Pediatric patients differ from adults in airway anatomy, normal vital signs, respiratory physiology, and responses to illness. These differences influence assessment, ventilation, medication dosing, defibrillation, and circulatory support.

Effective pediatric resuscitation depends on rapid recognition of deterioration, prompt support of airway, breathing, and circulation, identification of reversible causes, and continuous reassessment throughout treatment and recovery.

What Is Pediatric Advanced Life Support?

Pediatric Advanced Life Support (PALS) refers to advanced resuscitation and emergency care provided to infants and children who develop serious respiratory, circulatory, or cardiac problems. It builds on the principles of Basic Life Support while adding advanced airway management, cardiac rhythm interpretation, vascular access, medication administration, defibrillation, shock management, physiologic monitoring, and postresuscitation care.

Pediatric emergencies frequently begin with respiratory compromise rather than a sudden primary cardiac event. A child experiencing progressive airway obstruction, respiratory distress, or respiratory failure may eventually develop severe hypoxemia, bradycardia, cardiovascular collapse, and cardiac arrest. Early recognition and treatment are therefore essential.

Healthcare professionals involved in pediatric resuscitation must understand age-related physiology and recognize that normal findings vary considerably from infancy through adolescence.

Pediatric Assessment

Assessment begins as soon as the clinician encounters the child. The primary goal is to determine whether the airway, breathing, circulation, and neurologic status are adequate and whether immediate intervention is necessary.

Because pediatric patients can compensate for serious illness before deteriorating suddenly, seemingly subtle changes may be significant.

Normal Pediatric Respiratory and Heart Rates

Normal respiratory and heart rates vary with age. Approximate ranges include:

• Infants younger than 1 year: respiratory rate 30 to 60 breaths/min and heart rate 90 to 120 beats/min
• Toddlers 1 to 3 years: respiratory rate 24 to 40 breaths/min and heart rate 80 to 100 beats/min
• Preschool children: respiratory rate 22 to 34 breaths/min and heart rate 70 to 90 beats/min
• School-age children: respiratory rate 18 to 30 breaths/min and heart rate 70 to 90 beats/min
• Adolescents: respiratory rate 16 to 22 breaths/min and heart rate 60 to 80 beats/min

Note: These values must be interpreted in context. Fever, pain, anxiety, hypoxemia, dehydration, and other conditions may increase respiratory and heart rates.

Airway Assessment

The airway should be assessed for patency and signs of obstruction. The clinician should determine whether air is moving freely and whether breath sounds are present.

Possible signs of upper-airway obstruction include:

• Inspiratory retractions
• Stridor
• Reduced air movement
• Increased inspiratory effort
• Difficulty speaking or crying
• Weak or ineffective cough
• Cyanosis
• Altered mental status

Note: Inspiratory movement without effective air entry is particularly concerning because it may indicate severe or complete obstruction. Children have relatively small airways, so a small reduction in airway diameter from edema, secretions, or a foreign body can significantly increase resistance to airflow.

Breathing Assessment

Breathing should be evaluated for rate, effort, chest movement, and effectiveness.

Signs of increased work of breathing include:

• Nasal flaring
• Grunting
• Intercostal retractions
• Subcostal retractions
• Suprasternal retractions
• Accessory-muscle use

More concerning signs may indicate severe respiratory distress or impending respiratory failure. Head bobbing occurs when the chin rises and the neck extends during inspiration and then falls during expiration. This finding reflects increased respiratory effort and is especially concerning in infants.

Seesaw respirations occur when the chest retracts while the abdomen expands during inspiration. This paradoxical pattern suggests marked respiratory muscle dysfunction or fatigue.

A child whose respiratory effort initially appears vigorous may deteriorate as fatigue develops. A reduction in respiratory effort is not necessarily an improvement if oxygenation, ventilation, or mental status is worsening.

Neurologic Assessment

Mental status provides important information about cerebral oxygenation and perfusion.

A child may be:

• Alert
• Irritable or agitated
• Confused
• Sleepy
• Minimally responsive
• Unresponsive

Note: Agitation may occur early during hypoxemia. Progressive lethargy or unresponsiveness suggests more severe deterioration. A minimally responsive or unconscious child may lose the ability to maintain airway patency and protect against aspiration, increasing the need for advanced airway management.

Assessment of Circulation and Perfusion

Circulatory assessment extends beyond simply checking the heart rate or pulse. The clinician should evaluate whether enough blood is reaching vital organs.

Important findings include:

• Pulse quality
• Blood pressure
• Capillary refill
• Skin temperature and color
• Mental status
• Urine output

Normal capillary refill should generally occur in less than approximately 2 seconds. Delayed refill may suggest inadequate peripheral perfusion.

The skin, brain, and kidneys provide useful information about cardiac output. Cool extremities, altered mental status, or reduced urine output may indicate compromised circulation even before severe hypotension develops.

Children can maintain blood pressure during the early stages of shock through vasoconstriction and increased heart rate. Hypotension is therefore often a late and concerning sign of decompensation.

Pediatric Respiratory Support

Respiratory support is a major component of pediatric emergency care because respiratory problems are common causes of deterioration and cardiac arrest in children.

Treatment should address oxygenation, ventilation, airway patency, and airway protection.

Oxygen Therapy

Supplemental oxygen should be administered when necessary to maintain adequate tissue oxygenation.

Oxygen should be treated as a medication. The goal is not automatically to provide the highest possible oxygen concentration. Instead, oxygen should be titrated according to the child’s condition and clinical goals. Pulse oximetry is commonly used to evaluate oxygen saturation and monitor the response to therapy.

Potential delivery devices include:

• Nasal cannula
• Simple mask
• Aerosol mask
• Nonrebreathing mask
• High-flow nasal cannula

Note: The device selected depends on age, oxygen requirement, patient tolerance, respiratory effort, and severity of illness.

Noninvasive Respiratory Support

Children with respiratory distress who continue to breathe spontaneously may benefit from noninvasive forms of support.

These may include:

• High-flow nasal cannula
• Continuous positive airway pressure
• Noninvasive positive-pressure ventilation

Note: These therapies can improve oxygenation, reduce work of breathing, recruit collapsed alveoli, and improve ventilation in selected patients. The child must be monitored closely because respiratory failure may progress despite noninvasive support.

Bag-Mask Ventilation

Bag-mask ventilation provides immediate ventilatory support when spontaneous breathing is absent or inadequate. Successful bag-mask ventilation requires a patent airway, proper positioning, an effective mask seal, and appropriate ventilation.

Each breath should produce visible chest rise. Excessive ventilation should be avoided because it may cause gastric inflation and increase intrathoracic pressure.

Ventilation is particularly important during pediatric resuscitation because many pediatric cardiac arrests result from progressive hypoxemia or asphyxia.

Advanced Airway Management

Endotracheal intubation may be necessary when the child cannot maintain the airway, protect against aspiration, oxygenate adequately, or ventilate effectively. Prior to intubation, clinicians should evaluate the airway for features that may make direct laryngoscopy difficult.

Potential difficulties include:

• Previous difficult intubation
• Small jaw
• Limited mouth opening
• Restricted neck extension
• Facial or airway abnormalities
• Head or neck burns
• Prior radiation to the head or neck
• Masses involving the mouth or airway

Note: Alternative airway techniques may be needed when direct visualization is difficult. After endotracheal tube placement, correct positioning should be confirmed using clinical assessment and waveform capnography when available.

Capnography in Pediatric Emergencies

Capnography provides continuous measurement of exhaled carbon dioxide and can be useful for several purposes during pediatric resuscitation.

It can help:

• Confirm endotracheal tube placement
• Monitor ventilation
• Detect tube displacement
• Evaluate CPR effectiveness
• Identify changes associated with return of spontaneous circulation

During CPR, persistently low end-tidal carbon dioxide may indicate inadequate pulmonary blood flow caused by ineffective chest compressions. A PetCO₂ below approximately 10 mm Hg during CPR suggests that compression quality should be reassessed and improved.

If invasive arterial pressure monitoring is available, an arterial diastolic pressure below approximately 20 mm Hg may similarly suggest inadequate perfusion during compressions.

Foreign-Body Airway Obstruction

Foreign-body airway obstruction is an important pediatric emergency, particularly in younger children. Food, small objects, toys, seeds, and nuts are common causes. Organic foreign material can be especially problematic because it may absorb moisture, expand, and worsen airway obstruction.

Signs of Foreign-Body Aspiration

Foreign-body aspiration should be considered when a previously healthy child suddenly develops:

• Coughing
• Choking
• Dyspnea
• Stridor
• Cyanosis
• Unilateral wheezing
• Decreased breath sounds

Sudden unilateral wheezing in a child without a previous history of wheezing is an important clue.

Some foreign bodies enter the bronchial tree and may lodge in the right mainstem bronchus or its branches. Chronic or missed aspiration can cause recurrent pneumonia, persistent cough, localized wheezing, or symptoms that resemble asthma but fail to respond to typical therapy.

Mild Airway Obstruction

A child who can speak, cry, or cough forcefully is still moving air. In this situation, the child should generally be allowed to continue coughing while being monitored closely. Aggressive airway maneuvers may convert a partial obstruction into a complete obstruction.

Severe Airway Obstruction

Signs of severe obstruction include:

• Inability to speak or cry
• Weak or ineffective cough
• Minimal or absent airflow
• Severe respiratory distress
• Cyanosis
• High-pitched inspiratory sound
• Universal choking sign
• Progressive loss of consciousness

A responsive child with severe obstruction is treated with abdominal thrusts. Infants are treated differently. Cycles of five back blows followed by five chest thrusts are performed.

Persistent foreign bodies may require removal with laryngoscopy or bronchoscopy. In extreme situations involving complete obstruction that cannot be relieved, an emergency surgical airway may become necessary.

Shock in Pediatric Patients

Shock occurs when oxygen delivery to the tissues is inadequate or when tissues cannot properly use the oxygen being delivered. Without effective treatment, shock can lead to cellular dysfunction, organ failure, cardiovascular collapse, and death.

Pediatric shock is generally classified as:

• Hypovolemic
• Cardiogenic
• Obstructive
• Distributive

Hypovolemic Shock

Hypovolemic shock occurs when intravascular volume is reduced.

Possible causes include:

• Dehydration
• Vomiting
• Diarrhea
• Hemorrhage
• Fluid losses from burns

Note: Children can lose substantial fluid before obvious hypotension develops. Hemorrhagic shock is a form of hypovolemic shock caused specifically by blood loss.

Cardiogenic Shock

Cardiogenic shock occurs when the heart cannot generate adequate cardiac output.

Possible causes include:

• Myocarditis
• Cardiomyopathy
• Severe congenital heart disease
• Significant arrhythmias

Note: Because the primary problem is cardiac pump failure, excessive fluid administration may worsen pulmonary congestion or cardiac workload in some patients.

Obstructive Shock

Obstructive shock occurs when a mechanical or physiological obstruction prevents adequate cardiac filling or output.

Potential causes include:

• Cardiac tamponade
• Tension pneumothorax
• Pulmonary embolism

Note: Correction of the obstruction is necessary to restore normal circulation.

Distributive Shock

Distributive shock occurs when abnormal vascular tone causes inappropriate distribution of blood flow.

Examples include:

• Septic shock
• Anaphylactic shock

Note: Vasodilation and increased vascular permeability may reduce effective circulating volume even when the total body fluid volume has not initially decreased.

Pediatric Cardiac Output

Cardiac output equals heart rate multiplied by stroke volume.

Stroke volume is influenced by:

• Preload
• Contractility
• Afterload

Children rely heavily on heart rate to maintain cardiac output because their ability to significantly increase stroke volume can be limited. A substantial decrease in heart rate can therefore cause a marked decline in cardiac output and tissue perfusion.

This helps explain why severe pediatric hypoxemia can progress from respiratory distress to bradycardia and cardiac arrest.

Management of Pediatric Shock

The goals of shock treatment include restoring tissue perfusion, maintaining oxygen delivery, preventing organ injury, and correcting the underlying cause. Airway, breathing, and oxygenation should be addressed first.

Vascular access should then be established promptly. Peripheral intravenous access is generally attempted first. If IV access cannot be obtained rapidly during a critical emergency, intraosseous access can provide an alternative route.

Fluid Resuscitation

Isotonic fluid boluses may be used when intravascular volume depletion is present. Fluid therapy should be guided by clinical response and the type of shock. Repeated boluses may be required in some patients, while others, particularly those with cardiogenic dysfunction, require more cautious fluid administration.

Historically, pediatric shock algorithms have commonly described boluses of approximately 20 mL/kg with repeated reassessment.

The response to fluids should be evaluated by monitoring:

• Heart rate
• Blood pressure
• Pulse quality
• Capillary refill
• Mental status
• Lung sounds
• Urine output

Note: Hypoglycemia and hypocalcemia should also be identified and corrected when present.

Vasoactive Medications

When shock persists despite appropriate fluid therapy, vasoactive or inotropic medications may be required. Drug selection depends on the child’s hemodynamic condition.

Agents may include:

• Epinephrine
• Norepinephrine
• Dopamine
• Dobutamine

Epinephrine may be considered when cold shock and poor cardiac output predominate. Norepinephrine may be considered when warm shock and excessive vasodilation are prominent.

Patients with refractory circulatory failure may require advanced monitoring and specialized support. Extracorporeal membrane oxygenation may be considered in selected cases that do not respond to conventional treatment.

Septic Shock

Septic shock occurs when infection triggers widespread inflammatory and cardiovascular abnormalities that interfere with normal tissue perfusion. The inflammatory response may involve cytokines, coagulation pathways, complement, and immune cells.

Progressive sepsis can cause:

• Vasodilation
• Capillary leakage
• Reduced effective circulating volume
• Myocardial dysfunction
• Impaired oxygen utilization
• Multiple-organ dysfunction

Management includes early recognition, respiratory support, circulatory stabilization, fluid therapy when appropriate, and administration of antibiotics when bacterial infection is suspected.

Vasoactive therapy may be required when circulatory failure persists. Hydrocortisone may be considered in selected patients when adrenal insufficiency contributes to refractory shock.

Anaphylaxis

Anaphylaxis is a severe systemic hypersensitivity reaction that can produce rapid respiratory and cardiovascular compromise.

Inflammatory mediators such as histamine can cause:

• Vasodilation
• Increased vascular permeability
• Bronchoconstriction
• Airway edema
• Reduced effective circulating volume

Clinical findings vary widely.

Patients may develop:

• Urticaria
• Facial swelling
• Wheezing
• Stridor
• Hypotension
• Respiratory distress
• Gastrointestinal symptoms
• Dizziness
• Syncope

Anaphylaxis can occur without obvious skin manifestations. Airway compromise requires immediate attention. Supplemental oxygen and ventilatory support should be provided when necessary.

Epinephrine is the primary medication used for severe anaphylaxis. Patients with circulatory collapse may also require fluid resuscitation and repeated or continuous epinephrine therapy.

Bronchodilators may be used when bronchospasm persists. Antihistamines and corticosteroids may be used as additional therapy after immediate life-threatening problems have been addressed.

Recognition of Pediatric Cardiac Arrest

Cardiac arrest should be suspected when a child or infant is:

• Unresponsive
• Not breathing normally or only gasping
• Without a definite pulse within 10 seconds

Note: Breathing and pulse can be checked simultaneously. For children, the carotid or femoral artery may be assessed. For infants, the brachial artery is commonly used. If a pulse cannot be identified promptly, chest compressions should begin.

Pediatric Cardiopulmonary Resuscitation

High-quality CPR is essential during pediatric cardiac arrest. Chest compressions should be performed at a rate of approximately 100 to 120 compressions/min.

Compressions should be interrupted for less than 10 seconds whenever possible, and complete chest recoil should occur between compressions.

Compression Depth

• For a child, the chest should generally be compressed at least one-third of the anterior-posterior diameter, approximately 2 inches.
• For an infant, compression depth is approximately one-third of the anterior-posterior chest diameter, or about 1½ inches.

Infant Compression Technique

A single rescuer may use two fingers to compress the infant’s chest. When two or more rescuers are present, the two-thumb encircling-hands technique is preferred because it can generate more effective compressions.

Compression-to-Ventilation Ratios

For a single rescuer, the compression-to-ventilation ratio is:

30:2

When two healthcare providers are performing CPR on a child or infant, the ratio is:

15:2

Neonatal resuscitation generally uses a 3:1 ratio because neonatal cardiovascular collapse is commonly related to impaired gas exchange.

Once an advanced airway is established during pediatric cardiac arrest, chest compressions continue without pausing for breaths, while ventilation is delivered independently at the appropriate rate.

Emergency Response and AED Use

The timing of emergency activation depends partly on the circumstances of the collapse. For a witnessed sudden collapse, emergency response activation and retrieval of a defibrillator should occur promptly.

For an unwitnessed pediatric collapse, a lone rescuer may provide approximately 2 minutes of CPR before leaving the child to activate emergency services and retrieve an AED.

An AED should be applied as soon as it becomes available. Pediatric pads or an appropriate pediatric energy attenuator are preferred when available. If pediatric equipment is unavailable, adult AED pads may be used.

Pediatric Pulseless Arrest

Once CPR begins, a cardiac monitor or defibrillator should be attached to determine the cardiac rhythm. The main distinction is whether the rhythm is shockable or nonshockable.

Shockable rhythms include:

• Ventricular fibrillation
• Pulseless ventricular tachycardia

Nonshockable rhythms include:

• Asystole
• Pulseless electrical activity

Ventricular Fibrillation and Pulseless Ventricular Tachycardia

VF and pulseless VT require defibrillation. The initial pediatric defibrillation dose is approximately:

2 J/kg

If additional shocks are necessary, subsequent shocks are generally delivered at:

At least 4 J/kg

Immediately after defibrillation, CPR should resume for approximately 2 minutes. The rescuer should not delay compressions unnecessarily to repeatedly check for a pulse immediately after each shock.

During CPR:

• Establish IV or IO access
• Administer epinephrine at appropriate intervals
• Consider an advanced airway
• Use waveform capnography when available
• Search for reversible causes
• Continue rhythm reassessment

Note: Persistent shockable rhythms may require amiodarone or lidocaine.

Asystole and Pulseless Electrical Activity

Asystole and PEA are nonshockable rhythms. Defibrillation is not indicated.

Treatment includes:

• High-quality CPR
• IV or IO access
• Epinephrine
• Airway and ventilatory support
• Waveform capnography when available
• Identification of reversible causes

The rhythm should be reassessed after approximately 2-minute cycles of CPR. If the rhythm becomes shockable, treatment shifts to the VF or pulseless VT pathway.

If an organized rhythm appears, the pulse should be evaluated to determine whether return of spontaneous circulation has occurred.

Epinephrine During Pediatric Cardiac Arrest

Epinephrine is an important medication used during pediatric resuscitation. During cardiac arrest, it is typically repeated every:

3 to 5 minutes

All medication doses in pediatric emergencies must be calculated carefully because many drugs are administered according to body weight.

Accurate weight estimation and careful dose verification can help reduce medication errors.

Reversible Causes of Pediatric Cardiac Arrest

Resuscitation should include an ongoing search for reversible causes. A common framework is the 5 Hs and 5 Ts.

The 5 Hs

• Hypovolemia
• Hypoxia
• Hydrogen ion excess or acidosis
• Hypokalemia or hyperkalemia
• Hypothermia

The 5 Ts

• Tension pneumothorax
• Cardiac tamponade
• Toxins
• Pulmonary thrombosis
• Cardiac thrombosis

Identification and correction of one of these underlying problems may be necessary for successful resuscitation.

For example, CPR alone will not correct a tension pneumothorax. Likewise, persistent arrest caused by severe hypovolemia requires restoration of circulating volume.

Return of Spontaneous Circulation

Return of spontaneous circulation, commonly abbreviated ROSC, occurs when effective spontaneous circulation returns after cardiac arrest.

Possible signs include:

• Detectable pulse
• Measurable blood pressure
• Spontaneous movement
• Improved skin perfusion
• Abrupt increase in PetCO₂

Note: Once ROSC occurs, treatment immediately shifts toward postresuscitation care.

Postresuscitation Care

Successful resuscitation does not end when the pulse returns. The period after cardiac arrest is critical because the patient may continue to experience respiratory failure, circulatory instability, neurologic injury, metabolic abnormalities, and recurrent cardiac arrest.

Postresuscitation care focuses on supporting organ function while identifying and treating the cause of the arrest.

Respiratory Management

Oxygenation and ventilation should be closely monitored. Mechanical ventilation may be required.

Clinical assessment may include:

• Oxygen saturation
• Chest movement
• Breath sounds
• Capnography
• Blood gas analysis
• Patient-ventilator synchrony

Note: Ventilator settings should be adjusted according to the child’s size, condition, gas exchange, and response to treatment. Both severe hypoxemia and unnecessarily excessive oxygen exposure should be avoided when possible.

Cardiovascular Management

Cardiovascular monitoring may include:

• Electrocardiography
• Blood pressure measurement
• Laboratory testing
• Chest imaging
• Assessment of peripheral perfusion
• Urine output

Note: Fluids, vasoactive medications, or other circulatory support may be required. The clinician should continue searching for the precipitating cause of the original arrest.

Role of the Respiratory Therapist in PALS

Respiratory therapists are often directly involved in pediatric airway and respiratory management.

Responsibilities may include:

• Airway assessment
• Oxygen administration
• Bag-mask ventilation
• Endotracheal intubation assistance
• Mechanical ventilation
• Capnography
• Suctioning
• Bronchodilator administration
• Chest compression assistance
• Monitoring during resuscitation
• Postresuscitation respiratory care

Respiratory therapists may also assist with circulatory procedures, emergency medication delivery, defibrillation, and physiologic monitoring depending on institutional roles and scope of practice.

Knowledge alone is not sufficient. Pediatric resuscitation also requires practical proficiency with emergency equipment, teamwork, communication, and rapid decision-making.

Teamwork During Pediatric Resuscitation

Pediatric resuscitation is most effective when healthcare professionals function as a coordinated team.

Team members may be assigned specific responsibilities for:

• Chest compressions
• Airway management
• Ventilation
• Medication preparation
• Defibrillation
• Rhythm interpretation
• Documentation
• Leadership

Clear communication reduces confusion and helps important tasks occur at the correct time.

Closed-loop communication can be useful during high-stress situations. The team leader gives a clear instruction, the receiving team member confirms the instruction, and completion is reported back.

Family Presence During Resuscitation

Family members may sometimes remain present during pediatric resuscitation. When appropriate, a staff member can be assigned to remain with the family and explain what is occurring.

This team member may answer questions, provide emotional support, and help family members understand the interventions being performed. The decision should take into account patient care, family preferences, available personnel, and the clinical environment.

Termination of Pediatric Resuscitation

Decisions regarding termination of pediatric resuscitation are complex. No single factor reliably predicts whether continued resuscitation will be successful.

Factors that may be considered include:

• Duration of CPR
• Cause of the arrest
• Whether the event was witnessed
• Initial cardiac rhythm
• Subsequent rhythms
• Number of epinephrine doses
• Response to interventions
• Child’s age
• Presence of reversible causes

Note: These factors must be considered collectively rather than relying on one variable alone.

Importance of Continuous Reassessment

Pediatric Advanced Life Support requires continuous reassessment. The child’s condition may change quickly, and treatment that was appropriate several minutes earlier may no longer be sufficient.

Important findings to reassess include:

• Airway patency
• Respiratory rate
• Work of breathing
• Oxygen saturation
• Ventilation
• Heart rate
• Pulse quality
• Blood pressure
• Capillary refill
• Mental status
• Skin perfusion
• Urine output
• Response to medications and fluids

Note: Repeated reassessment allows clinicians to determine whether treatment is working and whether additional intervention is necessary.

Pediatric Advanced Life Support Practice Questions

1. What is Pediatric Advanced Life Support (PALS)?
Pediatric Advanced Life Support (PALS) is advanced emergency care for infants and children with life-threatening respiratory or cardiovascular problems.

2. What is the main goal of PALS?
The main goal of PALS is to rapidly recognize deterioration, support airway, breathing, and circulation, and treat the underlying cause of the emergency.

3. Why is age important when assessing pediatric vital signs?
Age is important because normal respiratory rate, heart rate, and other physiologic values change considerably as children grow.

4. What is the normal respiratory rate for an infant younger than 1 year?
The normal respiratory rate for an infant younger than 1 year is approximately 30–60 breaths/min.

5. What is the normal heart rate for an infant younger than 1 year?
The normal heart rate for an infant younger than 1 year is approximately 90–120 beats/min.

6. What is the normal respiratory rate for a toddler between 1 and 3 years of age?
The normal respiratory rate for a toddler between 1 and 3 years of age is approximately 24–40 breaths/min.

7. What is the normal respiratory rate for an adolescent?
The normal respiratory rate for an adolescent is approximately 16–22 breaths/min.

8. Which findings may indicate increased work of breathing in a child?
Accessory-muscle use, grunting, nasal flaring, and retractions may indicate increased work of breathing in a child.

9. What is head bobbing in a pediatric patient?
Head bobbing occurs when the chin rises and the neck extends during inspiration and then the chin falls during expiration.

10. What do seesaw respirations indicate in a pediatric patient?
Seesaw respirations can indicate severe respiratory distress or impending respiratory failure.

11. What occurs during seesaw respirations?
During seesaw respirations, the chest retracts while the abdomen expands during inspiration.

12. Why is declining mental status concerning in a pediatric emergency?
Declining mental status may indicate worsening oxygenation or perfusion and can impair the child’s ability to maintain and protect the airway.

13. What is considered a normal capillary refill time in a child?
Normal capillary refill generally occurs in less than approximately 2 seconds.

14. What may prolonged capillary refill indicate?
Prolonged capillary refill may indicate inadequate tissue perfusion and possible shock.

15. What is the purpose of supplemental oxygen in pediatric emergency care?
Supplemental oxygen is used to maintain adequate tissue oxygenation when a child’s oxygenation is insufficient.

16. Why should oxygen be treated like a medication?
Oxygen should be administered in the lowest amount necessary to achieve the desired clinical outcome and avoid unnecessary oxygen exposure.

17. What forms of noninvasive respiratory support may be used in pediatric patients?
High-flow nasal cannula, continuous positive airway pressure, and noninvasive ventilation may be used in selected pediatric patients.

18. When may endotracheal intubation be necessary in a pediatric patient?
Endotracheal intubation may be necessary when the child cannot maintain the airway, protect against aspiration, oxygenate adequately, or ventilate effectively.

19. What is one important use of waveform capnography after pediatric intubation?
Waveform capnography can help confirm proper placement of the endotracheal tube.

20. What does a PetCO₂ below approximately 10 mm Hg during CPR suggest?
A PetCO₂ below approximately 10 mm Hg during CPR suggests inadequate circulation from chest compressions and the need to improve CPR quality.

21. What finding should raise suspicion for foreign-body aspiration in a child without a history of wheezing?
Sudden unilateral wheezing should raise suspicion for foreign-body aspiration.

22. What should be done if a child with a foreign-body airway obstruction can still cough forcefully?
The child should generally be allowed to continue coughing while being closely monitored.

23. How is severe foreign-body airway obstruction treated in a responsive child?
Severe foreign-body airway obstruction in a responsive child is treated with abdominal thrusts.

24. How is severe foreign-body airway obstruction treated in a responsive infant?
A responsive infant with severe foreign-body airway obstruction is treated with cycles of five back blows followed by five chest thrusts.

25. What are the four major categories of shock in pediatric patients?
The four major categories of shock are hypovolemic, cardiogenic, obstructive, and distributive shock.

26. What is hypovolemic shock?
Hypovolemic shock is a form of shock caused by a loss of circulating blood volume or body fluid.

27. What are common causes of hypovolemic shock in children?
Common causes include dehydration, vomiting, diarrhea, hemorrhage, and fluid loss from burns.

28. What is cardiogenic shock?
Cardiogenic shock occurs when the heart cannot pump enough blood to maintain adequate cardiac output and tissue perfusion.

29. What are two possible causes of cardiogenic shock in children?
Myocarditis and cardiomyopathy are two possible causes of cardiogenic shock in children.

30. What is obstructive shock?
Obstructive shock occurs when a mechanical or physiologic obstruction interferes with cardiac filling or blood flow.

31. What are two examples of conditions that can cause obstructive shock?
Cardiac tamponade and tension pneumothorax can cause obstructive shock.

32. What is distributive shock?
Distributive shock occurs when abnormal vascular tone causes inappropriate distribution of blood flow and inadequate tissue perfusion.

33. What are two common examples of distributive shock?
Septic shock and anaphylactic shock are common examples of distributive shock.

34. What determines cardiac output?
Cardiac output is determined by heart rate multiplied by stroke volume.

35. What three factors influence stroke volume?
Stroke volume is influenced by preload, myocardial contractility, and afterload.

36. Why do children depend heavily on heart rate to maintain cardiac output?
Children have a limited ability to increase stroke volume, so heart rate plays a major role in maintaining cardiac output.

37. What routes may be used for vascular access during a pediatric emergency?
Peripheral intravenous, intraosseous, or central venous access may be used depending on the urgency and clinical situation.

38. When is intraosseous access especially useful?
Intraosseous access is especially useful when rapid vascular access is needed and peripheral IV access cannot be obtained promptly.

39. What type of fluid may be used for initial volume replacement in pediatric shock?
An isotonic crystalloid may be used for initial volume replacement when intravascular depletion is present.

40. What is a commonly referenced pediatric fluid bolus volume for shock?
A commonly referenced bolus volume is approximately 20 mL/kg, followed by reassessment of the patient’s response.

41. What findings should be monitored after fluid administration for shock?
Heart rate, blood pressure, pulse quality, capillary refill, mental status, lung sounds, and urine output should be monitored.

42. When may vasoactive or inotropic medications be needed in pediatric shock?
They may be needed when shock persists despite appropriate fluid resuscitation and treatment of the underlying cause.

43. Which vasoactive medication may be considered for cold shock?
Epinephrine may be considered for cold shock when poor cardiac output and vasoconstriction predominate.

44. Which vasoactive medication may be considered for warm shock?
Norepinephrine may be considered for warm shock when excessive vasodilation is a major problem.

45. What is septic shock?
Septic shock is circulatory failure caused by a severe systemic response to infection that impairs tissue perfusion and organ function.

46. What are important components of septic shock management?
Management includes airway and breathing support, circulatory stabilization, appropriate fluid therapy, antibiotics, and vasoactive support when needed.

47. What is anaphylaxis?
Anaphylaxis is a severe systemic hypersensitivity reaction that can cause airway edema, bronchoconstriction, vasodilation, and circulatory collapse.

48. What is the primary medication used to treat severe anaphylaxis?
Epinephrine is the primary medication used to treat severe anaphylaxis.

49. Can anaphylaxis occur without skin findings?
Yes. Anaphylaxis can occur without obvious skin findings such as hives or flushing.

50. What additional treatments may be used after epinephrine in anaphylaxis?
Additional treatments may include supplemental oxygen, fluid resuscitation, bronchodilators, antihistamines, and corticosteroids as clinically appropriate.

51. What findings are used to recognize pediatric cardiac arrest?
Pediatric cardiac arrest is suspected when the patient is unresponsive, is not breathing normally or is only gasping, and has no definite pulse within 10 seconds.

52. Which arteries are commonly used to check a pulse in a child?
The carotid or femoral artery is commonly used to check a pulse in a child.

53. Which artery is commonly used to check a pulse in an infant?
The brachial artery is commonly used to check a pulse in an infant.

54. How long should a pulse check last during pediatric resuscitation?
A pulse check should take no longer than approximately 10 seconds.

55. What is the recommended chest compression rate for children and infants?
The recommended chest compression rate is approximately 100–120 compressions/min.

56. How deep should chest compressions be performed in a child?
Chest compressions should reach at least one-third of the anterior-posterior chest depth, approximately 2 inches.

57. How deep should chest compressions be performed in an infant?
Chest compressions should reach approximately one-third of the anterior-posterior chest depth, about 1½ inches.

58. What compression technique is used by a single rescuer for an infant?
A single rescuer typically uses the two-finger technique for infant chest compressions.

59. What compression technique is preferred when two rescuers perform CPR on an infant?
The two-thumb encircling-hands technique is preferred when two rescuers perform CPR on an infant.

60. What compression-to-ventilation ratio is used by a single rescuer for a child or infant without an advanced airway?
The compression-to-ventilation ratio is 30:2.

61. What compression-to-ventilation ratio is used by two healthcare providers for a child or infant without an advanced airway?
The compression-to-ventilation ratio is 15:2.

62. What compression-to-ventilation ratio is generally used during neonatal resuscitation?
Neonatal resuscitation generally uses a 3:1 compression-to-ventilation ratio.

63. What happens to the compression pattern after an advanced airway is placed during pediatric CPR?
Chest compressions become continuous while ventilations are delivered independently without pausing compressions.

64. What should a lone rescuer generally do after an unwitnessed pediatric collapse?
The rescuer should provide approximately 2 minutes of CPR before leaving to activate emergency services and obtain an AED.

65. What should be done after a witnessed sudden pediatric collapse?
Emergency services should be activated and a defibrillator or AED obtained promptly.

66. Can adult AED pads be used on a pediatric patient if pediatric pads are unavailable?
Yes. Adult AED pads may be used if pediatric pads or an appropriate pediatric attenuator are unavailable.

67. Which pediatric cardiac arrest rhythms are considered shockable?
Ventricular fibrillation and pulseless ventricular tachycardia are considered shockable rhythms.

68. Which pediatric cardiac arrest rhythms are considered nonshockable?
Asystole and pulseless electrical activity are considered nonshockable rhythms.

69. What is the initial pediatric defibrillation dose for ventricular fibrillation or pulseless ventricular tachycardia?
The initial pediatric defibrillation dose is approximately 2 J/kg.

70. What energy level is generally used for subsequent pediatric defibrillation attempts?
Subsequent shocks are generally delivered at at least 4 J/kg.

71. What should be done immediately after delivering a shock during pediatric cardiac arrest?
CPR should resume immediately for approximately 2 minutes.

72. How often is epinephrine typically repeated during pediatric cardiac arrest?
Epinephrine is typically repeated every 3–5 minutes.

73. Which antiarrhythmic medications may be used for persistent shockable pediatric rhythms?
Amiodarone or lidocaine may be used for persistent ventricular fibrillation or pulseless ventricular tachycardia.

74. Why is defibrillation not used for asystole or pulseless electrical activity?
Asystole and pulseless electrical activity are nonshockable rhythms, so treatment focuses on CPR, epinephrine, airway support, and correction of reversible causes.

75. What is the purpose of searching for reversible causes during pediatric cardiac arrest?
The purpose is to identify and correct an underlying problem that may be preventing return of spontaneous circulation.

76. What are the 5 Hs that should be considered as reversible causes of pediatric cardiac arrest?
The 5 Hs are hypovolemia, hypoxia, hydrogen ion excess or acidosis, hypokalemia or hyperkalemia, and hypothermia.

77. What are the 5 Ts that should be considered as reversible causes of pediatric cardiac arrest?
The 5 Ts are tension pneumothorax, cardiac tamponade, toxins, pulmonary thrombosis, and cardiac thrombosis.

78. Why is hypoxia an especially important reversible cause in pediatric cardiac arrest?
Hypoxia is especially important because many pediatric arrests develop after progressive respiratory failure or asphyxia.

79. What is return of spontaneous circulation (ROSC)?
Return of spontaneous circulation is the restoration of effective spontaneous circulation after cardiac arrest.

80. What findings may indicate that ROSC has occurred?
Possible signs include a palpable pulse, measurable blood pressure, spontaneous movement, improved perfusion, and an abrupt increase in end-tidal carbon dioxide.

81. What is the main purpose of postresuscitation care?
The main purpose is to support organ function, treat the underlying cause of the arrest, and reduce further injury after circulation has been restored.

82. What respiratory parameters should be monitored after ROSC?
Oxygen saturation, chest movement, breath sounds, ventilation, capnography, and blood gas values should be monitored after ROSC.

83. Why may mechanical ventilation be necessary after pediatric cardiac arrest?
Mechanical ventilation may be necessary to support oxygenation and ventilation when spontaneous breathing remains inadequate after ROSC.

84. What cardiovascular assessments may be used after successful pediatric resuscitation?
Electrocardiography, blood pressure monitoring, laboratory testing, chest imaging, assessment of tissue perfusion, and urine output may be used.

85. Why is urine output useful during postresuscitation monitoring?
Urine output provides information about renal perfusion and the adequacy of overall circulation.

86. What is the role of the respiratory therapist during pediatric resuscitation?
The respiratory therapist may assist with airway management, oxygen delivery, bag-mask ventilation, intubation, mechanical ventilation, capnography, suctioning, and respiratory monitoring.

87. Why is teamwork important during pediatric resuscitation?
Teamwork allows multiple critical tasks to be performed efficiently and reduces delays, confusion, and communication errors.

88. What is closed-loop communication during a resuscitation?
Closed-loop communication occurs when an instruction is given, repeated or acknowledged by the receiving team member, and confirmed when the task is completed.

89. What responsibilities may be assigned to team members during pediatric resuscitation?
Responsibilities may include chest compressions, airway management, ventilation, medication preparation, defibrillation, rhythm interpretation, documentation, and team leadership.

90. Why may family members be allowed to remain present during pediatric resuscitation?
Family presence may provide emotional support and allow family members to understand what is happening when it can be done without interfering with patient care.

91. What role may a staff member have when family members remain present during resuscitation?
A staff member may stay with the family, explain procedures, answer questions, and provide support.

92. Why is termination of pediatric resuscitation a complex decision?
No single clinical factor can reliably predict the outcome of pediatric cardiac arrest, so multiple factors must be considered together.

93. What factors may be considered when deciding whether to continue pediatric resuscitation?
Factors include CPR duration, cause of arrest, whether the arrest was witnessed, initial and subsequent rhythms, epinephrine doses, age, response to therapy, and reversible causes.

94. Why is continuous reassessment important during PALS?
Continuous reassessment is important because a child’s condition can change rapidly and treatment may need to be adjusted based on the response.

95. What should be reassessed repeatedly during a pediatric emergency?
Airway patency, breathing, oxygenation, heart rate, pulse quality, blood pressure, perfusion, mental status, and response to treatment should be reassessed.

96. Why can a decrease in respiratory effort be concerning in a critically ill child?
A decrease in respiratory effort may indicate fatigue and impending respiratory failure rather than clinical improvement.

97. Why should excessive ventilation be avoided during pediatric resuscitation?
Excessive ventilation can cause gastric inflation, increase intrathoracic pressure, and reduce effective circulation.

98. Why are medication doses especially important to verify in pediatric emergencies?
Many pediatric medications are weight based, so dosing errors can occur if the child’s weight or calculation is inaccurate.

99. Why can pediatric patients deteriorate rapidly even after appearing relatively stable?
Children can compensate for respiratory or circulatory problems for a period of time and then decompensate quickly once those compensatory mechanisms fail.

100. What is the overall principle of Pediatric Advanced Life Support?
The overall principle of PALS is rapid recognition of deterioration followed by organized support of airway, breathing, circulation, treatment of reversible causes, and continuous reassessment.

Final Thoughts

Pediatric Advanced Life Support (PALS) combines rapid assessment, respiratory support, circulatory stabilization, high-quality CPR, defibrillation, emergency medications, monitoring, and postresuscitation care. Because respiratory failure and shock can progress rapidly in children, early recognition remains one of the most important aspects of pediatric emergency management.

Clinicians must understand age-related vital signs, signs of respiratory distress, shock states, cardiac arrest rhythms, airway obstruction, and weight-based therapies.

Effective PALS also depends on teamwork, frequent reassessment, and identification of reversible causes so that treatment addresses both the immediate emergency and the underlying problem.